- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.05 / $928.06 / $1,250.58
| Facility | | $329.05 | $928.06 | $1,250.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.05 / $329.05 / $329.05
| Professional | | $329.05 | $329.05 | $329.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.06 / $495.78 / $838.31
| Professional | | $329.06 | $495.78 | $838.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.43 / $310.43 / $329.05
| Facility | | $310.43 | $310.43 | $329.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.69 / $279.69 / $329.05
| Professional | | $279.69 | $279.69 | $329.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.44 / $329.05 / $533.32
| Professional | | $299.44 | $329.05 | $533.32 |